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As we head towards the general election, the NHS is a key concern for voters and is vying with Brexit as the issue they say is most likely to influence how they vote.

While public and patient satisfaction with health services remains high, the public are increasingly pessimistic about the future of the NHS.

An overwhelming majority of the public think the health service has a funding problem and increasing numbers of people would be prepared to pay more in tax or National Insurance to boost NHS funding.

The public remains wedded to the current NHS funding model and is, for the most part, not in favour of charging for services that are currently free, but there is some evidence the public would support stopping funding for treatments that are not perceived as clinically necessary.

With the pressures on the service unlikely to ease, the incoming government will find it difficult to ignore such high levels of public concern about the NHS.

Introduction

While Brexit continues to dominate the election campaign, the NHS remains a key concern for voters. In Ipsos MORI’s May 2017 Political Monitor, 43 per cent of respondents cited the NHS as one of the issues that will be most important to them in deciding how they vote (42 per cent said Europe/Brexit). While this finding may have been influenced by the impact of the recent cyber-attack on the service (it has jumped by 12 percentage points since April), there is no doubt that the NHS is at the forefront of people’s minds as polling day approaches. The Ipsos MORI/Economist May 2017 Issues Index found that 61 per cent of people identify the NHS as one of the most important issues facing the country, 16 percentage points above Brexit. This is the fifth highest level of concern recorded since 1997 and the highest it has been since April 2002, prior to Gordon Brown announcing £40 billion of extra funding for the NHS.

Despite this, in a Brexit-dominated campaign and with sharply polarised views about the strengths and weaknesses of the main parties, most commentators do not think the NHS will be a decisive factor at the ballot box. However, such high levels of public concern do suggest that the NHS will need to be a high priority for the incoming government. So, what will the public be looking for from politicians when it comes to the NHS?

Public and patient perceptions of the NHS

Surveys published over the past couple of years indicate that patient experience and public satisfaction with the NHS are holding up remarkably well given the widely reported pressures on the system.

The headline findings on public satisfaction with the NHS from the 2016 British Social Attitudes survey, provide a broad societal view of how the public views the NHS. They showed that overall satisfaction with the NHS remained at historically high levels with 63 per cent of respondents saying they were satisfied with the running of the NHS.

The CQC Inpatient Survey, measuring patients’ experience of hospitals, has shown continuous improvement over the past five years, an extraordinary achievement in challenging times. The GP Patient Survey has seen a fall in some scores – particularly around access to appointments – over the past few years, but in the 2016 survey 85 per cent of respondents rated their overall experience as good. So, the headline figures suggest that the public and patients are broadly happy with the service and have a positive view of the NHS. However, the picture is more complex than this.

The fieldwork period for the British Social Attitudes survey was July to October 2016, before the widespread media coverage of 2016/17 winter pressures in the NHS that might have affected public perceptions of the service. When we start to look at other sources, particularly more recent surveys, there is cause for increasing concern. In February 2017, the Ipsos MORI Issues Index, which charts the public’s views about the most important issues facing Britain, recorded the highest level of concern about the NHS since 2002. Pessimism over the future of the NHS is at record levels with 62 per cent of people thinking it is going to get worse over the next few years and only 15 per cent thinking it will get better. The trend is stark.

Cuts, funding and staff shortages

So, what is driving public concern? The answer from all recent sources points to the perceived lack of funding and the impact this is starting to have, particularly on staffing levels. Within the health care sector, the warnings around inadequate funding have been growing in number and volume over the past few years, and now seem to be cutting through with the public in a significant way. In the 2016 British Social Attitudes survey 82 per cent of respondents said that they thought the NHS was facing a major or severe funding problem, an increase of 10 percentage points over the past two years. In the same survey, of those who said they were dissatisfied with the running of the service, 45 per cent said it was because the government doesn’t spend enough money on the NHS while 48 per cent said it was because there were not enough staff.

An Ipsos MORI poll for the BBC, conducted in January 2017, came to very similar conclusions: the top three most commonly cited answers to the question ‘What, if anything, do you think currently puts pressure on the NHS to deliver the services it provides?’ related to funding and staff shortages. Recent focus group research conducted by BritainThinks on behalf of the Richmond Group suggested the public is starting to talk about a real crisis based on perceptions of a cash-strapped service that is straining to meet demand. So, what do the public think the possible solutions to this are and how far will politicians go to address these?

What do the public see as the solutions to the funding issues?

Fundamental change to the way we fund the NHS is one solution unlikely to gain traction with the public. In 2013, The King’s Fund, working with Ipsos MORI, asked members of the public to explore the acceptability of alternative funding models. The headline finding from this work was ‘Public remain wedded to NHS funding model’ but this headline does not reflect the reluctance participants displayed to moving away from a tax-funded system, free at the point of use. Indeed, the 2014 British Social Attitudes survey (when the question was last asked) found that 89 per cent of the general public agreed that the government should support a national health system that is tax funded, free at the point of use, and provides comprehensive care for all citizens. Only 2 per cent disagreed.

The recent Ipsos MORI polling for the BBC reinforced this finding with the majority of respondents favouring solutions within the current funding model. In this survey, 51 per cent of respondents said that moving to a type of insurance model for NHS funding was unacceptable, while only 37 per cent said they would accept this.

As the table below shows, one option, favoured by almost three-quarters of those surveyed, would be to increase charges for visitors from outside the UK. The BritainThinks focus groups found that some members of the public see extra demand on NHS services due to immigration as one of the root causes of the NHS’s funding problems. However, people appear to hold contradictory views about this, with some people seemingly thinking specifically about health tourism, others more generally about EU citizens. The complex nature of this immigration issue was underlined by a recent poll showing that 80 per cent of the public think special visas should be offered to EU citizens who want to work as doctors or nurses in Britain.

When it comes to the public paying more towards funding the NHS, increasing National Insurance is a more acceptable option for many than paying higher taxes, according to the Ipsos MORI poll for the BBC. It is difficult to know exactly what might be behind this preference: it may be that people see National Insurance more positively, as a contribution to services rather than a levy on their income, and as such, it is more acceptable to them. In this context, it is interesting to look back at how Labour Chancellor Gordon Brown’s 2002 National Insurance increase was seen by the public: an ICM poll at the time showed 76 per cent of all voters and 54 per cent of Conservative supporters supported the rise.

This starts to move the debate towards the concept of a hypothecated tax. Despite the drawbacks often cited about hypothecation, the British Social Attitudes survey suggests more support for a dedicated NHS tax – an idea proposed by the Liberal Democrats in their manifesto – than paying more through general taxation.

If the NHS needed more money, which of the following do you think you would be prepared to accept?

2014 (%)

2015 (%)

2016 (%)

Pay more through the taxes I currently pay

17

17

21

Pay more through a separate tax that would go directly to the NHS

24

24

28

Pay for non-medical costs in hospital, like food and laundry

12

12

11

Pay £10 for each visit to a GP or local A&E department

14

15

14

Ending exceptions from current charges

3

3

5

None of the above; the NHS needs to live within its budget

27

26

20

Don’t know

3

3

1

It goes without saying that there is a significant difference between people saying they would be willing to pay more towards the NHS and the reality of them being obliged to do so. However, the trend of opinion identified in the British Social Attitudes survey over the past three years might be taken as a sign that the British public is beginning to accept that it needs to pay more to retain the services it says it wants. The acceptability of paying more taxes has risen by 8 points between 2014 and 2016.

So, what are the public’s attitudes to solutions that place the responsibility on patients themselves rather than paying more via the government? The recent Ipsos MORI poll for the BBC suggests that most people (51 per cent) think charging for services that are currently free is unacceptable (37 per cent say it is acceptable) but this question only begins to touch on the hugely complex area of what people think the NHS should provide. The recently launched consultation into whether some products, such as suncream and gluten-free food, should continue to be available on prescription signals a move towards reducing the remit of the NHS. Findings from The King’s Fund/Ipsos MORI work in 2013 suggested there was some public acceptance of the idea that the NHS could stop funding ‘not clinically necessary’ procedures but what these procedures might be was a thornier issue.

The Ipsos Mori/BBC poll showed that 70 per cent of the population regarded charging patients for missed appointments as acceptable. However, it also showed that when it comes to paying for some services that are currently free the jury is still out: 43 per cent of the public were willing to pay an average of £11.08 for a guaranteed appointment with their GP within 24 hours, but 51 per cent were against it.

The debate with the public

The King’s Fund and others have argued that the NHS can no longer maintain quality of care and meet current standards with the budget it has been given and have called for an honest debate about the implications of this. The public is becoming increasingly aware that this debate has to happen. However, it is likely that any acceptable solution will be complex and will come with some form of cost in financial terms, through narrowing the remit of the NHS or in reducing the services provided.

In essence, the challenge facing the next government boils down to two questions: what are people prepared to pay for and how much are they willing to pay? Whether or not the NHS is a decisive factor in determining how people vote in an election overshadowed by Brexit, pressures on services are unlikely to ease and public concern about the NHS will continue to grow the longer these questions are left unanswered. Something has to give and the next government ignores this at its peril.